A lower body approach to lumbar pain in pitchers

What do gators, windmills, and lawnmowers all have in common? All three are nicknames for exercises that incorporate strengthening or stretching of muscles in both the lower back and the lower extremities. And all three are examples of tools baseball pitchers can use to prevent or rehabilitate from low back pain, according to Kevin Laudner, PhD, ATC, a professor of athletic training at Illinois State University in Normal.

Several studies1-3 published in the last decade suggest baseball pitchers are at risk for low back pain. Although researchers don’t yet fully understand the relationship between back pain and the soundness of the lower body, clinicians who treat baseball players increasingly are incorporating lower extremity exercises into rehab protocols for those suffering from low back pain and into training regimens to help reduce the risk.

Trunk motion in pitchers

Lower extremity exercises can help to prevent or manage pain in the lower back, said Laudner, whose 2013 study in the International Journal of Sports Physical Therapy4 found greater thoracolumbar range of motion (ROM) in asymptomatic baseball pitchers than in position players. The authors theorized that this finding may reflect adaptations to compensate for tightness in other joints, including the hip as well as the shoulder and elbow. They concluded that a better understanding of thoracolumbar ROM in both injured and uninjured baseball players would help clinicians develop a meaningful regimen to help prevent low back pain.

“Originally, we started seeing [low back pain] because nobody was doing anything in terms of strength and conditioning with the back,” Laudner said. “It was just with the shoulders because that’s where all the pain [initially developed]. Now we’ve seen kind of a shift where people are looking at it more functionally, from the hips through the back. From a performance standpoint, we feel like the pitchers are more effective if they can develop more strength in the lower extremities and back and transfer that through the shoulder.”

This concept is supported by early work from Japan, which found that overhead throwing velocity decreased by 36% when lower body movement was restricted, and decreased by another 10% when trunk motion was restricted.5 A 1991 modeling study also found that trunk movement restriction could diminish throwing velocity by half.6

Lumbopelvic control

Ajit Chaudhari, PhD, FACSM, an associate professor of Physical Therapy, Mechanical Engineering, Biomedical Engineering and Orthopedics at The Ohio State University in Columbus, has led two studies on the relationship between pitching and low back pain7,8 that suggest assessment of lumbopelvic control and training to improve that control would be useful for baseball pitchers.

It’s difficult to isolate the lumbopelvic region for analysis, and therefore few such studies have been done, Chaudhari said. But he and his colleagues found about half of the college pitchers they studied had poor lumbopelvic motor control, or an inability to stabilize during hip external and internal rotation.8

Even when lumbopelvic issues are identified, Chaudhari said, it’s unclear what exercises might help, so the area is often ignored. But, given research suggesting that hip rotation during pitching is associated with upper extremity loading,9 it makes sense that ignoring one segment of the kinetic chain can make other segments more vulnerable.

“If you have weakness, lack of control, or lack of mobility in any part of the body, that might affect the whole system,” said Chaudhari, who is also the cofounder of a company that manufactures a tool for measuring and training core stability. “What would make the most sense is to try to do a whole screen to find out where they are deficient.”

Time-loss consequences

Christopher L. Camp, MD, an assistant professor of orthopedic surgery at the Mayo Clinic in Rochester, MN, was the lead author on a 2016 study in the American Journal of Orthopedics1 that found the back and core account for up to 12% of time-loss injuries in Major League Baseball. The results of the study have led to new research that shows that more than 10% of the 50 most common professional baseball injuries are back-related.

“In another study [not yet published], we just looked up the fifty most common injuries in professional baseball,” Camp said. “Interestingly, six of the top fifty diagnoses were related to the back. This is an area gaining increased attention in baseball, and more
research is certainly needed.”

In another study, soon to be published in Sports Health, Camp and colleagues found that decreased hip motion (especially internal rotation) increases the risk of developing back and abdominal muscle injuries in professional baseball players.

“That supports the concept of the kinetic chain, where energy is transferred from the lower body to the upper body segment by segment. When one segment [such as the hips] is not in proper working condition, it places an increased load on the next segment [the back] and increases the risk for injury in that body region,” Camp said.

Strength and stabilization

Many practitioners strongly believe there is a relationship between lower extremity strength and conditioning and the types of injuries pitchers sustain, including low back pain.

“With respect to pitching, for a lot of pitchers, their legs will fatigue first and once that happens, the kinetic chain has a little hiccup in it,” said Joseph G. Wasser, a graduate assistant and PhD candidate in the University of Florida’s Department of Orthopedics and Rehabilitation in Gainesville. “So pitchers then try to compensate elsewhere and that is when they start to overuse the core or arm or shoulder. The nature of pitching is that you are going to use all of your muscle groups. You have to make sure the quads are strong, the hamstrings are strong, and the glutes especially.”

Wasser, the lead author of a two-part narrative review of concepts related to low back pain in baseball, which was published in Research in Sports Medicine2,3 earlier this year, said the overarching theme in current research is to focus on strength and stabilization so pitchers’ bodies can properly handle the day-to-day stress and time needed to be successful without injury.

“With training and exercises, the important thing to keep in mind is proper form and technique, whether pitching or hitting,” Wasser said. “You want to generate power from the whole body.”

Training tactics

While multiple studies have theorized that there is a link between a weak or inefficient lower extremity base and increased risk of low back pain in pitchers, few have provided solutions.

To that end, Laudner offered up the gator, windmill, and lawnmower stretching exercises—each of which involves the low back and lower extremities and could be combined with weights for strengthening. These exercises could be added to a daily training routine, Laudner said.

Anecdotally, Chaudhari said he’s found that few of the baseball players he’s worked with lack lower extremity strength, but noted it’s still critical to involve the legs in rehab (and regular activity) for everything from a shoulder injury to low back pain.

“Most pitchers who are doing rehabilitation for the shoulder, when they are doing that, their gut is just kind of hanging out,” Chaudhari said. “We ask them to focus on the pelvis, and that works by incorporating the lower extremities. So if they are standing on one leg [for the shoulder exercise], they are working those other areas as well.”

Other factors

Beyond finding ways to shore up the lower extremity base, practitioners point out there are many inherent risk factors for low back injuries—some of which are modifiable, some not. As in the general population, age and weight are common risk factors. Although some age-related muscle and joint degeneration is inevitable, athletes can slow the process with good training, including remaining at a healthy weight, Laudner said.

Chaudhari theorizes that inadequate coaching is another risk factor.

“Anecdotally, there are pitchers who have had a lot more coaching as kids versus those who have kind of done it on their own,” Chaudhari said. “Of those two, the ones who have kind of done it on their own tend to have poorer control. So, I think that’s a significant component. If you have a kid who has been trying to throw as hard as they can with no instruction, they tend to throw a lot more with their arm.”

Positive trends

A lack of attention to lumbar flexibility and core strengthening has long been an issue in baseball, Laudner said. But, like his colleagues, he has seen improvement since he started doing research in this area.

“It was a surprise to me [initially], working with pro baseball players,” Laudner said. “I was shocked at how tight and weak they were in their hips and low back. But I think that is getting better.”

Camp agrees. And although he’s seen improvement over the last decade, he is quick to point out that pitchers, like all athletes, must commit to their training regimens for lasting results—which, given the scheduling demands of professional baseball, can be a challenge.

“In addition to building strength/stability/flexibility, attention has to be paid to maintaining it. This can be very difficult over the long, day-in, day-out, rigorous season of professional baseball,” Camp said. “Many players are now focusing on total body exercises that go beyond just adding muscle mass. In recent years, the focus on core strength, agility, flexibility, balance, proprioception, and stabilization has been on the rise.”